Analysis of quality of life and reflux oesophagitis following Billroth II and Roux-en-Y gastrointestinal reconstruction for gastric cancer

Abstract

BACKGROUND

The choice between Billroth II and Roux-en-Y reconstruction after radical gastrectomy for gastric cancer (GC) affects the occurrence of reflux and the quality of life (QoL) in patients.

AIM

To investigate the QoL and reflux oesophagitis incidence in patients who underwent Billroth II or Roux-en-Y gastrointestinal reconstruction after radical gastrectomy for GC.

METHODS

One hundred patients with GC who underwent radical resection at our hospital between January 2023 and December 2024 were enrolled. The patients were divided into two groups based on the postoperative gastrointestinal reconstruction technique: The Billroth II group and the Roux-en-Y group, comprising 50 patients each. The incidence of gastroesophageal reflux within two weeks postoperatively was compared between the groups, including 24-hour reflux episodes, frequency of reflux episodes lasting > 5 minutes, and maximum reflux duration. The reflux symptom scores were measured. Nutritional indicators, including serum albumin (ALB), prealbumin (PA), and haemoglobin (Hb), were assessed 4 and 8 weeks postoperatively. The QoL was evaluated using the QLQ-C30 questionnaire. The incidence of reflux oesophagitis was monitored at 3 months of follow-up.

RESULTS

No significant differences were observed between the groups in terms of baseline clinical characteristics (P > 0.05). At 2 weeks postoperatively, the Roux-en-Y group exhibited significantly lower 24-hour reflux episodes, episodes lasting > 5 minutes, and maximum reflux duration than the Billroth II group (P < 0.05). The Roux-en-Y group exhibited significantly lower reflux symptom scores, including epigastric burning, acid regurgitation, upper abdominal distension, and upper abdominal pain, than the Billroth II group (P < 0.05). No significant differences were observed in the peripheral blood ALB, PA, or Hb levels at 4 and 8 weeks postoperatively between the two groups (P > 0.05). The QLQ-C30 scores at 4 and 8 weeks postoperatively were significantly higher in the Roux-en-Y group than in the Billroth II group (P < 0.05). At the 3-month postoperative follow-up, the incidence of reflux oesophagitis was 4.0% in the Roux-en-Y group, significantly lower than the 16.0% observed in the Billroth II group (P < 0.05).

CONCLUSION

Among patients with GC undergoing gastrointestinal reconstruction, Roux-en-Y procedures resulted in fewer cases of gastroesophageal reflux and milder symptoms than Billroth II procedures. Nutritional status was comparable postoperatively between the two reconstruction techniques. However, the former significantly affects the patients' QoL less favourably and exhibits a lower incidence of reflux oesophagitis, demonstrating considerable clinical significance.

Key Words: Gastric cancer; Gastrointestinal reconstruction; Billroth II procedure; Roux-en-Y procedure; Quality of life; Reflux oesophagitis

Core Tip: This study demonstrates that compared to Billroth II reconstruction, Roux-en-Y anastomosis significantly reduces the incidence of gastroesophageal reflux and reflux esophagitis, alleviates reflux-related symptoms, and improves postoperative quality of life (QoL) in gastric cancer patients after radical distal gastrectomy. Although operative time may be longer with Roux-en-Y, it offers superior long-term functional outcomes by minimizing bile reflux and associated complications, without compromising nutritional status. Roux-en-Y reconstruction is recommended for its enhanced QoL benefits and reduced reflux morbidity.

INTRODUCTION

Gastric cancer (GC) is a common malignancy of the digestive system in clinical practice. Survey data indicate that it ranks second in incidence and third in mortality among all malignant tumours in China[1,2]. Radical gastrectomy with adequate lymphadenectomy remains the cornerstone of curative therapy for resectable GC. However, the extent of resection and the choice of gastrointestinal reconstruction technique significantly influence postoperative morbidity, nutritional recovery, and long-term quality of life (QoL)[3,4]. Therefore, optimal gastrointestinal reconstruction is of paramount importance in reducing the incidence of postoperative complications, such as reflux, and maintaining patients’ QoL. Although perioperative chemotherapy or chemoradiotherapy is recommended for locally advanced disease, the surgical technique itself is an independent determinant of functional outcome[5]. The Billroth II and Roux-en-Y procedures are the most frequently employed reconstructive options after distal gastrectomy. The Billroth II technique offers straightforward manipulation and a long history of application, although it is prone to postoperative complications, such as bile reflux and oesophagitis. The Roux-en-Y procedure, an improved variant, reduces the incidence of reflux but involves relatively complex surgical manoeuvres. To date, no definitive clinical guidelines exist for selecting the ideal reconstruction method, especially with respect to reflux control and QoL preservation[6]. Consequently, it is necessary to analyse and clarify the incidence of gastroesophageal reflux following different gastrointestinal reconstruction techniques during GC surgery. This prospective comparative study was designed to evaluate the impact of Billroth II vs Roux-en-Y reconstruction on patient QoL and the occurrence of reflux oesophagitis after radical gastrectomy for GC, thereby providing evidence for optimising surgical strategies beyond mere oncological adequacy. We hypothesized that Roux-en-Y reconstruction would result in a lower incidence of postoperative reflux and reflux oesophagitis, as well as improved postoperative QoL, compared with the Billroth II procedure.

MATERIALS AND METHODS

General data

One hundred patients with GC who underwent radical resection at our hospital between January 2023 and December 2024 were enrolled. Inclusion criteria: (1) Pathologically confirmed primary GC[7] without evidence of metastasis; (2) Eligibility for radical resection; (3) Age 18-70 years; (4) Life expectancy of ≥ 6 months; (5) KPS score > 70; (6) Willingness to comply with treatment and follow-up; and (7) Informed consent for participation. The exclusion criteria were as follows: (1) Severe concomitant cardiac, hepatic, or renal dysfunction; (2) Concurrent malignant tumours or metastatic lesions; (3) History of gastroesophageal surgery; (4) Concurrent haematological or immunological disorders; and (5) Cognitive or psychiatric impairment. The cohort comprised 57 males and 43 females; ages ranged from 37 to 64 years, with a mean of (51.37 ± 4.62) years; body mass index (BMI) ranged from 18.7 to 24.0 kg/m², with a mean of (20.74 ± 1.22) kg/m². TNM staging: TNM staging was determined by the 8th edition AJCC/UICC criteria and is summarised in Table 1: Stage I (T1-2 N0 M0, 12 cases), stage II (T1-2 N1-3 M0 or T3-4a N0 M0, 68 cases), and stage III (T3-4a N1-3 M0 or T4b any N M0, 20 cases); no patient had distant metastasis (M1) at surgery. Stage I (12 cases), Stage II (68 cases), Stage III (20 cases); tumour longest diameter: 2.8-4.3 cm, mean (3.12 ± 0.63) cm; tumour location: Gastric antrum/gastric angle (79 cases), gastric body (21 cases). This study was approved by the hospital ethics committee. The sample size was calculated a priori using PASS 2021 based on the primary endpoint of the 3-month incidence of reflux oesophagitis. A two-arm superior design was used. According to our pilot data (n = 20), the expected incidence was 15% after Billroth II and 3% after Roux-en-Y. With α = 0.05 (two-sided), power = 0.80, and a 1:1 allocation, the minimum number required per group was 43. Allowing for a 15% dropout rate, the final target was set to 50 patients per arm (n = 100).

Table 1 Comparison of clinical baseline characteristics between groups, n (%).

Items	Research group (n = 50)	Control group (n = 50)	t/χ2	P value
Sex
Male	28 (56.0)	29 (58.0)	0.108	0.084
Female	22 (44.0)	21 (42.0)
Age, year, mean ± SD	51.26 ± 4.57	51.43 ± 4.61	0.229	0.104
BMI, kg/m2, mean ± SD	20.61 ± 1.25	20.78 ± 1.18	0.317	0.091
TNM stage
I	5 (10.0)	7 (14.0)	0.806	0.773
II	35 (70.0)	33 (66.0)
III	10 (20.0)	10 (20.0)
Longest diameter of the tumour, cm, mean ± SD	3.14 ± 0.58	3.11 ± 0.66	0.477	0.116
Tumour location
Gastric antrum/gastric angle	39 (78.0)	40 (80.0)	0.916	0.265
Body of stomach	11 (22.0)	10 (20.0)

BMI: Body mass index.

Methods

All patients underwent pre-operative correction of anaemia and electrolyte imbalance using nasogastric tubes inserted for gastric pH monitoring and guidance on polyethylene glycol administration. The procedures were performed under general anaesthesia with endotracheal intubation. Following anaesthetic induction, the surgical site was disinfected, CO₂ pneumoperitoneum was established, and laparoscopic exploration was conducted to determine the precise lesion location, disease staging, and relationship with adjacent tissues. Regional lymph node dissection (D2 standard) was performed with high vagotomy and ligation/division of the relevant vessels (preserving only two short gastric vessels and the posterior gastric vessels). The gastric wall was then removed. A 5 cm midline suprapubic incision was made to provide laparoscopic access. The duodenum was transected 3 cm distal to the pylorus, and the gastric body was transected 5 cm proximal to the tumour margin. Subsequent gastrointestinal reconstruction was performed using a stapler-facilitated triangular anastomosis technique. The specific surgical procedure was as follows.

Roux-en-Y procedure: Approximately 10 cm distal to the ligament of Treitz, the small bowel segment was closed and transected using an 80 mm cutting stapler. Subsequently, a 1 cm incision was made at the gastric stump, into which a disposable cutting stapler was inserted to perform a side-to-side anastomosis between the gastric stump and distal jejunum. Subsequently, the common opening was closed with a stapler, and bleeding was controlled using a mucosal electrosurgical unit. A side-to-side anastomosis was performed between the proximal and distal jejunum approximately 40 cm from the gastrojejunal anastomosis, using an anastomosis stapler. The lateral incision was closed using a cutting stapler, and bleeding was controlled using an electrosurgical unit. Finally, the anastomotic and closure sites were reinforced using 4-0 micro-sutures.

Billroth II procedure: A 5 mm incision was made in the jejunum at the jejunal-mesenteric border, approximately 25 cm distal to the ligament of Treitz. A second 5 mm incision was made along the anastomotic line on the greater curvature of the residual stomach. Anastomosis was completed using an 80 mm straight cutting stapler, with the anastomotic line positioned on the greater curvature.

All patients received postoperative treatment with analgesics and anti-infective agents, along with nutritional support and early rehabilitation interventions.

Observation indicators

(1) Postoperative reflux status: Observe and record the occurrence of gastroesophageal reflux within two weeks post-surgery, including 24-hour reflux frequency, frequency of reflux episodes lasting ≥ 5 minutes, and maximum duration of reflux episodes; (2) Reflux symptom score: The severity of postoperative reflux symptoms, including heartburn, acid regurgitation, upper abdominal bloating, and upper abdominal pain, was assessed using a scoring scale. The scores ranged from 0 to 3, corresponding to no symptoms, mild, moderate, and severe symptoms, respectively[8]; (3) Postoperative Nutritional Indicators: Peripheral venous blood samples were collected at 4 and 8 weeks postoperatively to measure haemoglobin (Hb), albumin (ALB), and prealbumin (PA) levels; (4) Postoperative QoL was assessed 4 and 8 weeks postoperatively using the functional domain module of the QLQ-C30 questionnaire. This evaluates physical, role, cognitive, emotional, and social functioning, each scored out of 100, with higher scores indicating better QoL[9]. The Cronbach's α for this questionnaire was 0.875; and (5) Incidence of reflux oesophagitis: The number of cases of reflux oesophagitis occurring within 3 months postoperatively in both groups was monitored during follow-up, and the diagnosis was confirmed by hospital examination.

Statistical analysis

Clinical indicator data were statistically analyzed using SPSS 24.0. Normally distributed quantitative data are presented as mean ± SD, with intergroup comparisons conducted via t-tests. Categorical data are expressed as n (%), and intergroup comparisons were performed using the χ² test. Statistical significance was set at P < 0.05. Male: 57 cases; female: 43 cases; age range: 37-64 years; mean age: (51.37 ± 4.62) years; BMI: 18.7-24.0 kg/m², mean (20.74 ± 1.22); TNM staging: Stage I (12 cases), stage II (68 cases), stage III (20 cases); tumour longest diameter: 2.8-4.3 cm, mean (3.12 ± 0.63) cm; tumour location: Gastric antrum/cardia (79 cases), gastric body (21 cases).

RESULTS

Comparison of basic clinical characteristics between groups

Patients were categorised into the Billroth II and Roux-en-Y groups based on the type of gastrointestinal reconstruction procedure performed, comprising 50 cases in each group. No significant differences were observed in the basic clinical characteristics between the two groups (P > 0.05), rendering them comparable (Table 1).

Comparison of postoperative reflux occurrence between groups

At two weeks postoperatively, the Roux-en-Y group exhibited significantly lower 24-hour reflux episodes, frequency of reflux episodes lasting > 5 min, and maximum reflux duration than the Billroth II group (P < 0.05) (Table 2).

Table 2 Comparison of postoperative reflux occurrence between groups, mean ± SD.

Group	Case	Number of reflux episodes within 24 hours	> 5 minutes reflux frequency	Longest duration of reflux (minutes)
Research group	50	5.14 ± 1.25	1.05 ± 0.58	5.71 ± 1.03
Control group	50	7.02 ± 1.17	2.36 ± 0.41	6.33 ± 1.21
t		7.772	13.041	2.761
P value		0.000	0.000	0.006

Comparison of reflux symptom scores between groups

Assessment revealed that the Roux-en-Y group exhibited lower symptom scores for heartburn, acid regurgitation, upper abdominal distension, and upper abdominal pain than the Billroth II group (P < 0.05) (Table 3).

Table 3 Comparison of postoperative reflux symptom scores between groups, points, mean ± SD.

Group	Case	Heartburn	Acid reflux	Upper abdominal distension	Upper abdominal pain
Research Group	50	1.14 ± 0.25	1.08 ± 0.37	1.22 ± 0.41	1.06 ± 0.26
Control group	50	2.01 ± 0.34	1.95 ± 0.40	2.03 ± 0.37	1.94 ± 0.18
t		14.571	11.290	10.372	19.681
P value		0.000	0.000	0.001	0.000

Comparison of postoperative nutritional markers between groups

Testing revealed no significant differences in the peripheral blood ALB, PA, or Hb levels at 4 and 8 weeks postoperatively between the groups (P > 0.05). However, the levels at 8 weeks were higher than those at 4 weeks in each group (P < 0.05) (Table 4).

Table 4 Comparison of postoperative nutritional indicator levels between groups, mean ± SD.

Group	Case	Hb (g/L)		ALB (g/L)		PA (mg/L)
		Post-4 weeks	Post-8 weeks	Post-8 weeks	Post-8 weeks	Post-8 weeks	Post-8 weeks
Research group	50	62.18 ± 5.37	81.16 ± 6.14a	37.73 ± 3.11	52.18 ± 4.98a	292.74 ± 11.46	332.47 ± 13.16a
Control group	50	63.07 ± 5.73	80.47 ± 6.23a	37.91 ± 3.18	51.23 ± 4.17a	292.09 ± 11.24	330.87 ± 12.76a
t		0.801	0.561	0.292	1.033	0.289	0.623
P value		0.425	0.578	0.775	0.301	0.771	0.538

^aP < 0.05 vs 4 weeks post-surgery within the group.

ALB: Albumin; PA: Prealbumin; Hb: Haemoglobin.

Comparison of postoperative QoL between groups

Assessment using the QLQ-C30 questionnaire at 4 and 8 weeks postoperatively revealed significantly higher scores in the Roux-en-Y group than in the Billroth II group (P < 0.05) (Table 5).

Table 5 Comparison of postoperative quality of life between groups.

Group	Case	Bodily functions		Role function		Cognitive function		Emotional function		Social function
		Post-4 weeks	Post-8 weeks	Post-4 weeks	Post-8 weeks	Post-4 weeks	Post-8 weeks	Post-4 weeks	Post-8 weeks	Post-4 weeks	Post-8 weeks
Research group	50	51.45 ± 3.22	73.42 ± 4.19a	51.84 ± 2.36	73.11 ± 3.48a	50.78 ± 3.86	70.45 ± 3.12a	51.22 ± 2.29	75.74 ± 3.62a	50.19 ± 3.18	71.12 ± 4.29a
Control group	50	51.63 ± 3.14	62.35 ± 4.23a	51.92 ± 2.28	60.71 ± 3.17a	50.86 ± 3.75	60.13 ± 3.24a	51.89 ± 2.31	63.68 ± 3.46a	50.22 ± 3.24	60.63 ± 4.13a
t		0.281	13.152	0.168	18.619	0.112	16.229	1.460	17.032	0.052	12.501
P value		0.780	0.001	0.863	0.001	0.917	0.000	0.148	0.001	9.963	0.000

^aP < 0.05 vs 4 weeks post-surgery within the group.

Intergroup comparison of postoperative reflux oesophagitis incidence

At the 3-month postoperative follow-up, the incidence of reflux oesophagitis was 4.0% in the Roux-en-Y group and 16.0% in the Billroth II group, representing a significant intergroup difference (P < 0.05) (Table 6).

Table 6 Postoperative incidence of reflux oesophagitis between groups, n (%).

Group	Case	Reflux oesophagitis
Research group	50	2 (4.0)
Control group	50	9 (16.0)
χ2		8.169
P value		0.010

DISCUSSION

Radical surgical resection remains the most effective treatment for GC. With recent advances in clinical techniques, laparoscopic technology has been successfully applied as a minimally invasive approach to GC surgery. However, distal gastrectomy alters gastrointestinal anatomy and physiological function, predisposing patients to postoperative gastrointestinal complications that significantly affect their QoL and psychological well-being[10,11]. The current academic consensus supports simultaneous gastrointestinal reconstruction following radical surgery. Clinically, diverse reconstruction techniques exist, with the Billroth II and Roux-en-Y procedures being the most prevalent. Among these, Billroth II is the most widely used. It offers operational simplicity, is not restricted by tumour size, and can be performed even when the pylorus is involved. Furthermore, it utilises a highly mobile jejunum for anastomosis with the gastric stump, effectively avoiding the risk of excessive anastomotic tension associated with the Billroth I procedure. However, Billroth II anastomosis alters the physiological flow of food, making postoperative symptoms such as reflux more likely to occur[12,13]. The Roux-en-Y procedure represents a refinement of the Billroth II, preserving jejunal continuity while mitigating the reflux risk to some extent[14,15]. Currently, no unified standard exists for selecting gastrointestinal reconstruction methods after radical gastrectomy for GC. Furthermore, research on these techniques has primarily focused on the surgical procedures themselves, with limited follow-up studies on postoperative reflux oesophagitis and patient QoL. Consequently, it is imperative to conduct in-depth investigations into the impact of these two surgical approaches on the patients’ postoperative QoL and the incidence of reflux-related symptoms.

We conducted a comparative investigation of the QoL and reflux oesophagitis following Billroth II and Roux-en-Y gastrointestinal reconstructive procedures in patients undergoing radical gastrectomy for GC. All operations were performed under general anaesthesia with strict adherence to standard surgical protocols. Regarding the postoperative reflux incidence at two weeks post-surgery, the Roux-en-Y group exhibited significantly lower 24-hour reflux episodes, 5-min reflux frequency, and maximum reflux duration than the Billroth II group (P < 0.05), consistent with findings from relevant studies[16-18]. This finding indicates that Roux-en-Y reconstruction is more effective in controlling postoperative reflux. Concurrently, the Roux-en-Y group exhibited lower scores for postoperative epigastric burning, acid regurgitation, upper abdominal distension, and upper abdominal pain than the Billroth II group (P < 0.05). It is evident that Roux-en-Y reconstruction reduces the incidence of reflux and significantly improves patients’ subjective symptoms. This symptomatic relief may be directly related to a decrease in reflux episodes because reflux is the primary cause of these symptoms[19]. This necessitates that clinicians prioritise the consideration of postoperative reflux when selecting gastrointestinal reconstruction methods for GC surgery, particularly in patients with a high risk of reflux[20].

This study compared the effects of these two surgical techniques on postoperative recovery. Results demonstrated that Peripheral serum ALB, PA, and Hb levels were comparable at 4 and 8 weeks after surgery. This indicates that neither technique significantly affected the patients’ nutritional status postoperatively, with both procedures facilitating a satisfactory recovery. This finding aligns with previous research conclusions regarding early postoperative nutritional recovery, indicating that both surgical approaches provide a relatively stable nutritional support environment during the early postoperative period[21]. QoL scores at 4 and 8 weeks postoperatively were higher across all dimensions than those in the Billroth II group, consistent with the findings of Yang et al[22]. This indicates that Roux-en-Y reconstruction not only improves the patients’ nutritional status but also significantly enhances their QoL. This advantage may be related to the anatomical and physiological characteristics of the Roux-en-Y reconstruction. By altering the anatomical structure of the digestive tract, Roux-en-Y reconstruction reduces gastric reflux, thereby lowering the incidence of complications, such as reflux oesophagitis, and improving patients’ dietary experience and psychological state. Moreover, Roux-en-Y reconstruction preserves the gastrointestinal integrity and promotes nutrient absorption, thereby providing robust support for postoperative recovery. Additionally, a 3-month follow-up revealed a reflux oesophagitis incidence of 4.0% in the Roux-en-Y group and 16.0% in the Billroth II group. This indicates that the Roux-en-Y reconstruction is more effective in reducing postoperative reflux oesophagitis. Roux-en-Y reconstruction effectively reduces gastric reflux into the oesophagus by altering the gastrointestinal connections, thereby lowering the incidence of reflux oesophagitis. This may have resulted from the establishment of a side-to-side anastomosis between the stomach and jejunum, allowing food to bypass the duodenum. Consequently, exposure of the oesophageal mucosa to gastric acid and pepsin is reduced, diminishing the risk of oesophagitis[23]. In contrast, although Billroth II reconstruction remains a common gastrointestinal reconstruction method after GC surgery, it is associated with a higher incidence of reflux oesophagitis. This may be related to the anatomical structure of the Billroth II reconstruction, which preserves a substantial portion of the stomach. This retention facilitates the reflux of gastric acid and pepsin into the oesophagus, thereby increasing the risk of reflux oesophagitis[24,25].

This study has some limitations that should be acknowledged when interpreting the findings. First, although baseline demographics and tumour-related characteristics were comparable between the groups, the set of covariates adjusted for was limited; variables such as pre-operative comorbidity burden (e.g., diabetes, cardiovascular risk), operative time, blood loss, adjuvant therapy regimen, and socioeconomic status were not included in the multivariable model. Consequently, residual confounding factors cannot be excluded and may introduce bias into the estimated associations between reconstruction type, reflux events, and QoL scores. Second, the follow-up duration was restricted to three months, a window that may capture early post-operative morbidity, but is insufficient to detect late sequelae such as anastomotic stricture, chronic Roux stasis syndrome, nutritional deficiencies, or cancer recurrence. These long-term outcomes are particularly relevant to the QoL and may ultimately outweigh the early benefits observed with Roux-en-Y reconstruction. Future multicentre cohort studies with extended follow-up and comprehensive covariate collection are warranted to validate our results and establish whether early advantages persist beyond the first post-operative year.

However, several limitations should be acknowledged. First, this was a single-center study with a relatively small sample size, which may limit the generalizability of the findings. Second, non-randomized allocation of reconstruction techniques introduces the potential for selection bias. Third, the short follow-up period of three months captures only early postoperative outcomes and does not account for long-term complications such as Roux stasis syndrome, anastomotic stricture, or late nutritional deficiencies. In addition, potential confounding factors, including variations in surgeon experience, operative time, intraoperative blood loss, and adjuvant therapy regimens, may have influenced postoperative QoL and reflux outcomes. Future multicenter randomized controlled trials with longer follow-up and comprehensive adjustment for these variables are needed to confirm the present findings and provide more robust evidence for optimal reconstruction strategy selection.

CONCLUSION

In summary, during gastrointestinal reconstruction following radical gastrectomy for GC, the Roux-en-Y procedure demonstrated a lower incidence of gastroesophageal reflux and milder symptoms than the Billroth II technique. Nutritional status showed no significant difference between the two reconstruction methods; however, the Roux-en-Y approach had a lesser impact on the patients' QoL and was associated with a lower incidence of reflux oesophagitis. Consequently, it should be prioritised in clinical practice based on patient preferences. The follow-up period in this study was relatively limited, covering only the three-month postoperative. This may be insufficient for a comprehensive assessment of long-term changes in the patients' QoL and nutritional status.